DammProfessional paper04-17-22 (4)

Alleviating Loneliness in a Vibrant Environment:
A. L. I. V. E.
A Journey to Culture Change in Long-Term Care
By
Sally A. Damm
B.S., Huron College, 1977
A Professional Report Submitted in Partial Fulfillment of
The Requirements for the Degree of
Master of Science
Administrative Studies Program
In the Graduate School
The University of South Dakota

Table of Contents
Abstractpage3
Verification Statementpage4
Chapter 1page5
Purpose of this Studypage6
Author’s Role in Organizationpage7
Organizational Historypage7
The Problems with Nursing Homespage10
National Ombudsman Reporting Systempage11
The NewsHour with Jim Lehrerpage12
Chapter 2page19
The Culture Change Toolpage20
Chapter3page28
Preparing for the Transitionpagepage29
Implementationpagepage31
Figures
Figure 1.
Figure 2.
Figure 3.
Figure 4.
Figure 5.
Figure 6.
Figure 7.

Figure 8.
Figure 9.
Figure 10.
Figure 11.
Figure 12.
Figure 13.
Figure 14.
Figure 15.
Tables
Table 1.
Table 2.
Table 3.
Table 4.
References
Appendixes
ii

Abstract
This study examines the revolutionary journey that one facility has taken over the
past 10 years to transition from a medical model to a resident centered home for the
elderly. The movement sweeping the nursing home industry in this country is referred
to as culture change. This project documents a paradigm shift away from a staff
directed medical treatment to a resident centered environment that focuses on “living in
a nursing home” rather than “dying at the nursing home”. The result of this study gives
substance to the words “Alleviating Loneliness in a Vibrant Environment”. It documents
living in a nursing home can only be advanced when the leadership adopts a major
change in principles and works toward making actual concrete changes to policies and
practices within the physical environment. This includes management of staff,
empowerment of residents, the education of federal and state licensing agencies and
the community at large.
The facility in this study had a positive image in the community. It had a
successful history of caring for the resident using a model that mirrored the hospital’s
delivery system. This nursing home confronted the uncertainties of long-term-care and
responded to the new consumers’ demands by pledging to change the culture of the
nursing home. This shift of the day-to-day duties away from institutional efficiencies and
medical emphasis to focusing on the consumers’ strengths, desires, likes, dislikes,
routines, needs, and social interests has brought a positive result in several areas.
Culture change can be defined as a nursing home shifting from a cold, sterile, hospital

model to an environment that is more centered on the individual needs and unique
preferences of the people who live and work in the facility.
Verification Statement for the MSAS Professional Report
In preparing my MSAS Professional Report, I held myself to a standard of
academic honesty. Academic honesty includes drawing on the work of others in
preparing my Professional Report. I recognized that when I utilized other’s facts or
ideas I made the appropriate citation in the body of the Professional Report, followed by
the appropriate citation in the reference page.
Further, in preparing my Professional Report I did not use the assistance of an
editor other than my advisor. If I did use the assistance of an editor following is the
name and identification of the editor:
Janet Brubakken
1807 Half Moon Road
Brookings, SD 57006
My signature attests that this MSAS Professional Report represents my own
work and that any editorial assistance I had in its preparation was minor.
________________________
Signature
Sally Damm______________
Printed/Typed Name
3

April 01, 2007_____________
Date
4

The purpose of this study is to document a journey of transition from a medical
model to a resident centered home for the elderly. The movement sweeping the
nursing home industry in this country is referred to as culture change. The documented
paradigm shift away from a staff directed medical routine toward a resident centered
environment that focuses on “living in a nursing home” rather than “dying at the nursing
home” is the basic premise of this philosophy. This sense of living in a nursing home
can only be advanced when the leadership adopts a major change in principles and
works toward making actual concrete changes to policies and practices within the
physical environment. This includes management of staff, empowerment of residents,
and the education of federal and state licensing agencies and the community at large.
Historically, this nursing home cared for the residents using a model that mirrored
the hospital’s delivery system. Culture change is a shift of the day-to-day duties of this
nursing home away from institutional efficiencies and medical emphasis to focusing on
the consumers’ strengths, desires, likes, dislikes, routines, needs, and social interests.
Culture change can be defined as a nursing home shifting from a cold, sterile, hospital
model to an environment that is more centered on the individual needs and unique
preferences of the people who live and work there.
Alleviating Loneliness in a Vibrant Environment (A.L.I.V.E) has been a maturing
philosophy of this author for many years. As a high school student and nursing
assistant at the local nursing home in the early 1970’s, this author began a career
dedicated to healthcare. A.L.I.V.E. was not an acceptable philosophy of elder care for
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the next 30 plus years. The author and the facility staff against all odds pushed through
barriers and implemented the philosophy of A.L.I.V.E.
The author of this report currently is employed as the Administrator and is
responsible for the key services provided by this innovative and progressive 79 bed
Skilled Nursing Home with a 36 bed Assisted Living facility, a 24 apartment complex,
Adult Day Care Program, Respite Care Services and a nationally certified Child
Development Center program for 50 children. All these programs are found on one
intergenerational campus. This organization is certified for participation in the programs
as directed by the Center for Medicare and Medicaid Services (CMS) for the elders and
children that are served.
This free standing facility originated in 1959 by the citizens of the Brookings area.
This organization remains free standing at the present time; however, it became
affiliated with Avera McKennan Health System under a management agreement in
2006. This facility is in a rural community of approximately 18,000 people approximately
an hour away from the Sioux Falls metropolitan area in southeastern South Dakota. The
community is also home to a land grant university.
This corporation is home to residents from age 34 to 104 years, shares space
with children from 4 weeks to 6 years of age, and averages 150 plus employees. This
establishment allows residents to bring their personal pets that meet the safety and
health requirements to live in their home. This institution also has live-in dogs, cats,
birds, plants and a rabbit. This facility was part of the first wave of facilities on the
cutting edge of culture change as the Alleviating Loneliness in a Vibrant Environment
(A.L.I.V.E.) philosophy continues to expand, develop and divide into cells producing
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living, breathing neighborhoods within the facility. During the last ten years under the
leadership of the administrator, this facility has reached out to the community as a
resource service that has endeavored to enhance the quality of care and life its
customers desire and deserve.
This long-term-care home is one of only a few intergenerational care facilities in
South Dakota, and is the only one that integrates the curriculum for children with elders
to the extent that this facility does. Originally, the intergenerational culture change was
met with significant resistance. Because the philosophy implementation involved
significant levels of change for all of the facility departments (house-keeping, dietary,
nursing, social work, etc.), some of the staff were resistant to change. Some battled the
change while others embraced it, and still others chose to leave the facility to work
elsewhere. Many community members were also critical of the mixing of the
generations, and the novelty of a facility that looked and felt much like a family home
rather than a housing unit exclusively for medically needy elders seemed risky. The
leadership and employees committed to preserving the quality of daily medical care but
adopting the culture changes needed to bring “home” back into the nursing home
equation. The leadership continued to be persistent even in the light of strong
confrontation. One of the largest community concerns was the marriage of one of health
care’s lowest cost margin services with another very low cost margin service: childcare.
The apprehension of the community was alarming to this author in that the elderly could
physically or emotionally injure the children, and that the children could expose the
elders to childhood diseases.
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This organization had a successful history of management and care delivery
system; therefore, there were those that were happy with the status quo. Because of the
guidance of the administrator and the leadership team, department managers, and
community supporters not one of the original fears related to developing culture change
have been realized.
The following two sources give the staggering problems that nursing homes face
today. A national study that was aired on National Public Television in 2001 gathered
data that supports the fact that 50% of Americans would be reluctant to move from
home into a nursing home if the need arose. The majority of the public judge that people
who enter a nursing home never leave until death occurs, and nearly 50% of the public
believes that living in a nursing home affects people negatively in all areas of their life
(Jim Lehrer/Kaiser Family Foundation/Harvard, 2001).
Rosalie and Robert Kane in a publication co-authored with Dick Ladd, “The Heart
of Long-term Care”, 1998 states that the bulk of the regulations are based not on
realistic evidence of what activities are associated with better outcomes, but on
professional judgments which quickly approach rules and mandates. Strict statements
about what should be done for whom become rapidly restrictive at a time when long-
term-care is starved for modernization and creativity. There is limited confirmation about
how to deliver the best care and with the knowledge that there is every likelihood that
more than one way is available to achieve a positive outcome, it is premature to
become inflexible or settle on only one method of transforming the culture of the nursing
home.
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This author will address the issue of society’s attitude that a nursing home is a
place for the dying rather than a home for the living. By using the A.L.I.V.E concept,
implementing the programs over a period of 10 years and allowing it to grow, mature
and finally drill deep into the very fabric of the nursing home is just one way to change
the negative image of nursing homes from a “place to die” to a “home in which to live”.
The Problem with Nursing Homes:
Nationally, from 1996 to 2000, the number of grievances submitted to nursing
home staff increased. (Department of Health and Human Services, JULY 2003 p6) If the
grievances were unresolved to the customer’s satisfaction the complaints were
reviewed by state officials. On occasion the federal agency would review the
investigative results and issue a statement of their findings. The categories
of complaints did not change significantly according to the National Ombudsman
Reporting System (NORS) even after the implementation of the national nursing home
reform mandates referred to as the Omnibus Budget Reconciliation Act 87. (OBRA 87)
(Department of Health and Human Services, JULY 2003 p8) Nationally, the NORS
documents that the total number of nursing home complaints increased from about
145,000 in 1996 to roughly 186,000 in 2000. During the same time frame, the number of
objections per 1,000 beds climbed from 78.4 to 102.1. This denotes a 28 percent
increase in the number of complaints and a 30 percent increase in the number of
criticisms per thousand beds. (Department of Health and Human Services, JULY 2003
p10)
The nature of these complaints reported to NORS since 1996 have not been
modified significantly. Nationally, each of the top 12 complaint groupings remained in
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the top 12 between 1996 and 2000. In 2000, these top 12 categories accounted for
more than one-third of the total number of complaints. The allocation of complaints per
1,000 beds shows a comparable uniformity according to the NORS.
According to the NORS the highest occurrences of nursing home complaints
involve resident care. By 1999, complaints regarding resident care (e.g., accidents, not
responding to call lights, patient symptoms unattended) had exceeded those concerning
resident rights (e.g., abuse, access to information, issues about transfer and discharge).
From 1996 through 2000, resident care accusations escalated 37 percent compared to
a 21 percent growth for complaints involving resident rights. As of 2000, 6 of the top 10
identifiable complaint categories were related to resident care.
The NORS has recorded the following complaints as the top six concerns in
nursing homes across the nation:
1. failure to answer to call lights or requests for assistance
2. accidents and inappropriate handling of residents
3. lack of satisfactory care plans and resident assessments
4. incompetent administration of medications
5. unattended resident triggers
6. inadequate personal hygiene
(Department of Health and Human Services, JULY 2003, p 9)
According to the NORS, one of the major changes (for categories with at least
1,000 complaints in the year 2000) is that of complaints regarding staff turnover
increased by approximately 208 percent between 1996 and 2000. (Department of
Health and Human Services, JULY 2003, p15)
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Abuse cases reported to NORS spiked in 1998 and have dropped about 3
percent since then. The total for all reported abuse cases increased from 13,469 in
1996 to 15,501 in 1998, and declined to 15,010 in 2000. Physical abuse was the most
common type of abuse reported. (Department of Health and Human Services, JULY
2003 p10)
A second non governmental national survey completed for The NewsHour with
Jim Lehrer, the Kaiser Family Foundation, and the Harvard School of Public Health
finds that Americans see an important role for nursing homes in providing care for
individuals that are not able to care for themselves, yet they express significant
concerns about the care provided in nursing homes. The majority of the public have the
perception that nursing homes are staff challenged, that staff training programs are
lacking, that residents are abused and neglected, that privacy is limited or does not
exist, that personal belongings are lost or stolen, and that many residents are lonely.
(The NewsHour with Jim Lehrer, 2001)
About half of Americans would rather die than move into a nursing home if the
situation arose that they could not take care for themselves at home. (Department of
Health and Human Services, JULY 2003 p10)
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According to the NewsHour with Jim Lehrer the vast majority of the public
believes that most people entering a nursing home never go home, and nearly half the
public believes that once people enter the nursing home their condition worsens and
that they will die.
Approximately one third of people utilizing a nursing home have made a
complaint to the administration of a nursing home. Often these complaints were not
resolved to their satisfaction and one in ten continued their request upward to a state or
federal government agency, according to The NewsHour with Jim Lehrer report.
Figure 1 Public Perceptions of Nursing Home Residents
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Nursing homes receive mixed ratings from Americans with about a third of the
respondents saying that nursing homes are doing a good job serving health care
consumers (34%). However, 66% of the people rated the facility below acceptable
outcomes. Americans agree (52%) that nursing home residents participate in more
recreational and social activities than when they were living at home, however, 44% do
not agree with this belief (The NewsHour with Jim Lehrer, 2001 p28)
Figure 2 Public Perceptions of Nursing Home Staff
14

Figure 3. Positive Public Perceptions about Nursing Homes
The general public (50%) believes nursing home residents do not live in clean
facilities. A large majority (80%) consider nursing homes understaffed, and (65%) of
Americans think the staff at nursing homes are inadequately trained as reported by the
televised NewsHour with Jim Lehrer on public television in 2001. (The NewsHour with
Jim Lehrer, 2001 p28)
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Another frightening statistic reported on the The NewsHour with Jim Lehrer
referred to the public image, perceptions and factual experiences that were reported.
Nationally, 77% of these surveyed believe the staff neglects and overmedicate at least
some nursing home residents respectively. Approximately two thirds or (67%) respond
that staff abuse and use physical restraints on nursing home residents.
Figure 4 Negative Public Perceptions about Nursing Homes
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Figure 5. Public Experiences with Nursing Homes
It is unfortunate that six in ten of the survey populace thinks that residents are not
treated with dignity, nor do they have privacy, and that their personal belongings are lost
or stolen within the institutional setting. Finally, the majority of (63%) the public
perceives that many or almost all nursing home residents feel lonely, isolated, and have
less than adequate recreational and social activities.
In 2002, Mr. Larry Minnix, President and CEO of the American Association of
Homes & Services for the Aging, (AAHSA) identified technology and financing as the
two greatest uncertainties facing the elder care industry (The Long and Winding Road,
2006 p16). Today, technology is transforming the way elder care is delivered and the
long-term-care financing system as we know it today is unsustainable. A mere four
years later two very different uncertainties were identified in the publication by this
national association. The Long and Winding Road of 2007 as published by AAHSA
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identifies consumer expectations and the availability of a talented labor force as the
challenges of the future coupled with sustaining financial solvency and technology
modernization. (Minnix, 2007 p38-39)
Even without this knowledge and before the trends had been identified, studied
and published, the administrator this facility in 1997 made a decision to move from the
medical model to a more social home-like atmosphere. The staff of this facility took
proactive steps to address the challenges that have become nationally identified as the
leading uncertainties of long-term-care and took the long journey to resident centered
care outcomes.
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Alleviating Loneliness in a Vibrant Environment (A. L. I. V. E.) has a clear goal:
to reduce the percentage of negative images of the public by demonstrating through
action, word, and deed that a resident can live in a positive environment and receive
positive care within a nursing home.
The Culture Change Tool:
The culture change tool was first conceived in 2001 by Karen Schoeneman and
Mary Pratt of CMS, who were co-project officers of the CMS Quality of Life study in
(Bowman, 2006) nursing homes as led by Dr. Rosalie Kane of the University of
Minnesota. (Kane, Kane, & Ladd, 1998) The tool fills the purpose of collecting the
major concrete changes homes have made or are making in resident care and
workplace practices, policies, schedules and the resident centered care environment.
(Bowman, 2006) (Appendix A)
The culture change tool was issued in 2007 for use by the long-term-care
industry upon written request from Schonememan or the CMS agency. This tool has no
facility bench marks or comparison data to date. However, it is the goal for this tool to
be used by the industry and CMS to work together to bring forth a positive change to the
long term care industry in the 21st
Century. (Bowman, 2006)
Eight facility’s leaders completed the tool for the first time in February of 2007
using their historical knowledge of the former medical model and the present birthing of
the resident centered model. The results are not research-validated measures, nor are
they a sign of deficiencies. This tool is intended to represent a change in heart, mind
and attitude within the facility itself and includes vision and leadership.
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This tool confirms that culture change is a journey and is not a singular item that
can be duplicated in every nursing home across the nation. To change culture means
to know the culture, traditions, values and expectations of the community within and
outside the four walls which the residents call home. The scoring system begins at zero
for each facility and the benchmark becomes the total possible score for a home that
has achieved a perfect score. This facility’s score is 286.75 out of a possible 500.
The score documents the journey of this facility over the past ten years and the
growth potential needed to reach a score of 500. Those involved in the journey are
making progress with movement toward more change to come as residents and
employees work together to effect the culture within the walls of this facility.
CarePractices Enviroment Family&Community Leadership WorkplacePractice Outcomes Total
PotentialPoints 70 320 30 25 70 65 580
Survey1 30 134 20 5 24 57 270
Survey2 51 89 25 0 30 57 252
Survey3 56 269 25 21 68 47 486
Survey4 36 72 25 10 21 57 221
Survey5 41 79 25 18 36 64 263
Survey6 42 90 20 3 44 48 247
Survey7 35 96 20 10 33 61 255
Survey8 50 124 20 8 41 57 300
Average 42.625 119.125 22.5 9.375 37.125 56 286.75
PotentialPoints 70 320 30 25 70 65 580
PercentageofPotential 60.89 37.22 75 37.5 53 86 49
ArtifactsTotal
Table 2. Culture Change Date for the Organization
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0
100
200
300
400
500
600
700
Care Practices Enviroment Family and
Community
Leadership Workplace
Practice
Outcomes Total
Potential Points
Average
Figure 7. Culture Change Potential and Actual Points
This facility’s 10 year journey of culture change occurred when the historical
medical model was allowed to erode and a new path was slowly carved into the day-to-
day operations. The medical model in which employees direct, schedule and perform
the day to day living cares to the residents is crumbled by the shear power of a new
flowing mind set. Leadership must empower the residents to work with the staff closest
to the resident to seek out, develop and plan individual schedules for personal needs,
wants, desires, interests, events, and levels of involvement.
The shift away from a staff driven environment of tasks, decisions, timelines,
pills, treatments and cares performed to and for the resident has been a long standing
acceptable viewpoint. Styling the day-to-day events, tasks, activities and shaping
personal cares to enhance the resident centered care plan within an environment much
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like one’s own home takes a radical attitude adjustment. Culture change is based on an
environmental makeover.
Turnover of staff is the most researched outcome of culture change. Key items
indicate that the success of the culture change at this facility is staggering and worthy of
interest. Staff turnover at this facility prior to 1997 was averaging over 100%. Nationally
the average turnover rate is 81% in long-term-care facilities. Over the past seven years
at this facility the turnover rate has leveled to an average rate of 13 to16%.
The occupancy rate for this long-term-care facility has averaged 95% to 97%
over the past seven years. The South Dakota Department of Health reports a 71%
occupancy rate, and in some areas of the less populated parts of the state the
percentage is even lower.
Customer Satisfaction Rating
Roles in the Environment 3.5 - 3.7
Dining Room 2.7
Recreation 3.5 - 3.7
Table 3. Customer Satisfaction
Qualitatively at this facility program benefits are seen for both children and elders
as they interact. Elders have greater opportunities to be active with young children,
increasing their number of positive interactions with others, and allowing the building of
relationships with the children. One particular elder comes to the infant room every day
to hold the infants and interact with them. She sees it as her job to help the new infants
in the center adjust to the environment by holding, cuddling, and responsively
interacting with them. Her volunteer time in the infant room serves a strong purpose for
her life. Parents have reported during the first funding cycle that one of their initial
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concerns has not been realized: their children are not afraid of elders or the
“grandparents” living in the center. Instead, the children have developed positive
relationships with them. Parents have also noticed that their children’s awareness of
and acceptance of wheelchairs has transferred to when they are in public places.
Rather than staring at the person in a wheelchair, they now greet the individual or they
may ask a person who uses a wheelchair if he or she needs help. The child then may
hold the door for him or her when given an affirmative reply.
Quantitatively, the most noted benefit was the decrease in various infections in
the elders who lived at the center – especially involving skin infections. These were
measured in the frequency of infections before the child center opened and compared
to the frequency of infections after its opening. The most noticeable results are the
following:
• Skin infections (before mean = 11.3, after mean = 7.0, t = 1.43, p < .17;
approaching significance);
• Urinary Tract infections (before mean = 16.33, after mean = 10.2, t = 1.86,
p < .08; approaching significance);
• Respiratory infections (before mean = 18.3, after mean = 10.3, t = 2.16, p
< .05);
• *GI Tract infections and Conjunctivitis (the other two types of infections
tracked) have had a continued low incidence throughout the entire data
collection period.
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Before Child
Center After Child Center
Skin Infections 11.3 7
Urinary Tract Infections 16.33 10.2
Respiratory Infections 18.3 10.3
GI Tract Infections and
Conjunctivitis * *
* Insufficient Data
Table 4 Quantitatively Results
Customer satisfaction surveys at this facility indicate that all elements measured
received a rating that ranged from very good to excellent (many rating between 3.5 to
3.7) with the exception of the dining room experience (mean = 2.7). The rating scale
ranged from 4 = excellent to 1 = poor. The elements on the satisfaction survey
included: roles in the environment (i.e. the administrator, the director of nursing, the
social worker, nursing staff and certified nursing assistants, registered dietitian and
dietary staff, child care staff, recreational therapy, housekeeping, business office
personnel, volunteers, maintenance and chaplain). It included experiences such as
cleanliness, temperature, atmosphere, elements of the meals, and recreational
experiences. The recreational experiences received the highest rating of all (mean
range of 3.5 to 3.7) – this included planned intergenerational activities. The presence
of the children is benefiting the elders in that there is a trend for them to be healthier
with fewer infections, and that the elders are benefiting the children by giving them
positive experiences and a better perspective of older people.
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Turnover of Staff
Nationally 81%
Prior to 1997 >100%
After 1997 13% - 16%
Table 5. Turnover of Staff
The A.L.I.V.E. philosophy has resulted in an impressive reduction in facility
deficiencies during the annual surveys over the past seven years. According to the
official web site, Medicare Nursing Home Compare this facility in 2003 received a
deficiency free annual survey. As the implementation of A.L.I.V.E philosophy became
increasingly acceptable by the state survey team there has been no level of harm
deficiency identified higher than a potential for minimum harm (1) or minimum of
potential of harm (2) on a scale of one to four.
Increasing numbers of nursing homes are moving from the traditional medical
model to a more life-affirming resident-directed care continuum. Fewer than one
percent of America’s 17,000 nursing homes have made a deep system change to their
physical, psycho-social, spiritual and organizational environments, according to the
NORS. (Department of Health and Human Services, JULY 2003 p 6-3) Taking a
modernistic look at how services have been provided in the past presents opportunities
to revise the status quo and improve residents’ and employees’ quality of life. Nursing
homes are undertaking the grueling process of fundamentally changing the culture of
the organization with marked enhancement in resident satisfaction, staff retention and
recruitment. Facilities willing to change may risk survey deficiencies or reimbursement
difficulties. There will be personal transformations which involve assessing values and
attitudes, and in finally shaking the long held belief that medical models reflect a nursing
home with emphasis on “nursing”. “Emphasizing (home) with nursing as one service
26

that is provided is a paradigm shift. Medical therapy should be the maid of original
human caring, never its master.” (William H. Thomas, M.D., 1999 p 212)
Culture-change fosters relationships by putting the person before the task. It
promotes growth and development with a shift of decision making to the residents
and/or the employees closest to the residents. This empowerment embarks on culture
change aimed at restoring self-determination in facilities that resemble a personal
atmosphere of living rather than dying.
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Chapter 3
Conclusion
and
Recommendations
The quality of a nation is reflected in the way it recognizes that its strength
lies in its ability to integrate the wisdom of its elders with the spirit and vitality of
its children and youth. Margaret Mead
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This facility’s history is known for its high degree of innovative methods and
proactive approach to elder care. The A.L.I.V.E project was born out of that culture that
has brought intergenerational activities, events and therapies in which children
consistently and constantly interact with elders. This philosophy continues to enhance
and stimulate within the facility programming to meet the needs of the community.
This nursing facility sought a balance that would allow progressive achievement
and compliance with state and federal requirements, while simultaneously ensuring
optimal well-being for residents with a wide range of extremes in age, acuity level,
physical independence, cognitive ability and customer expectations. A further challenge
was to sustain a positive labor force within financial restraints.
To design, develop and implement culture change, this facility’s administrator
had to cultivate a significant level of cooperation with key staff in each department, the
Board of Directors and the community. To advance culture change a shift to a resident
centered care philosophy and its principles was implemented. Through educational
opportunities held on and off campus for staff, a slow, consistent and progressive
change began to emerge. These steps are referred to as “warming the soil” as
described by Dr. William Thomas M.D., founder of the Eden Alternative philosophy.
(Thomas, 1999 p 213)
Preparing for the Transition:
To prepare for the transition from a medical model to a resident centered
philosophy the administrator of this facility began an educational tour of the local
community. The educational sessions were presented to board members, families,
residents, staff and the community. The sessions had two purposes. The first was to
29

inform the public that this facility was actively pursuing solutions to balance the negative
societal attitude that one goes to hospitals to get well and nursing homes to die.
Second, was to share with those in attendance how this facility under its administrator’s
leadership was intending to address the negative image.
Monthly newspaper articles were written by the facility staff to keep the public
informed of the day to day activities and events that occurred. A 30 minute live, call-in
radio program referred to as “Long-Term-Living” was introduced. The administrator of
this facility read articles and shared these articles with the public.
A partnership was developed with the land grant university colleges of Early
Childhood Development, Engineering, Nursing, Family Consumer and Sciences,
Pharmacy and the various agricultural departments. The students are part of the
workforce at the facility. The university has approved the facility has a work study site
for the students. Students work with the facility to complete internship programs,
preceptor programs, classroom assignments and service learning opportunities. The
facility gains the enthusiasm of university students and the most update research in
their respective areas.
Gathering information, forming partnerships and educating of the community is
an ongoing and necessary staple to ensure the continued success of culture change.
The leadership of each facility must find methods for implementing culture change and
brand it uniquely the “homes” The implementation of the A.L.I.V.E philosophy and the
steps taken to date is neither a recipe for success nor step by step instructions for the
execution of future programs. The steps taken can be used a guideline for achieving
change in elder care.
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Implementation 1998
The first animals this facility introduced were 21 birds housed in a large aviary.
This was a very acceptable step with regulatory agencies and the public. The birds
were contained and there was no human contact between the people and the birds.
The birds were colorful, sang beautiful melodies, they were fun to watch and the
residents enjoyed listening to the chatter of the song birds. Today this facility is home to
more than 40 birds. The bird cages are found in resident rooms, in the rehabilitation
area and hallways for all to enjoy.
Another segment that contributed to the success of this culture change process
was the administrator attending and participating in national convocations concerning
the developing public concerns of the services provided by long term care facilities. By
attending national educational sessions the administrator was exposed to useable
research and become more informed of the negative images of nursing homes. The
administrator was pleasantly surprised to find that others serving in the long-term-care
industry were working toward changing the negative images of nursing homes across
the nation.
These experiences gave the administrator the courage to continue the quest to
replace the medical regulated model with a more home style atmosphere. This was a
delightful return to earlier experiences as a nursing home caregiver.
The sharing of this information with the board of directors, staff, residents,
families and the public at large was extremely important. Through this knowledge the
facility’s leader gained support to move forward with the A.L.I.V.E. project. This
approval contributed to the success and survival of culture change movement.
31

The second animal introduced to the facility was a cat named Shadow. Then two
more cats, then the fourth cat joined the family. At this time a request was received
and approval was granted for a new resident to bring her privately owned cat to live with
her in her new home. Both the resident and her friend Kitty had care plans. A staff
member and a local veterinarian addressed the medical needs of Kitty. The care team
included Kitty on the resident’s care plan. This method used by this facility to ensure the
health of the animal and the individualized resident care plan was accept by the
licensing agency.
Shadow was the catalyst that advanced the need for a written policy and
procedure to address the A.L.I.V.E project. The policy reads as follows: “All animals
entering this facility to live will be certified “clean”, receive appropriate treatments, and
receive all necessary annual shots by a licensed veterinarian before entering the facility.
The medical records of each animal will be kept for public review. The animals are to
been seen by a licensed veterinarian at least annually, during any suspected illness or
injury and if there is a single question as to the wellness of the animal.” This is the only
policy and procedure made for the introduction of the A.L.I.V.E. program at this facility.
(Facility manual 1999)
As with all new “introductions” to the culture change environment there were a
number of apprehensions, questions and concerns expressed to the administrator. The
negative predications, questions or concerns expressed by staff, residents, or families
never materialized. Today this facility has three resident owned cats and six cats that
are owned by the facility.
32

In 1999, a puppy named Sassy was admitted. This was the most difficult step
and by far the most controversial. Sassy was a black lab puppy with all the puppy
behaviors both positive and the negative. The human failure in this situation was
evident. A puppy needs uniform and routine training. This type of training is not
possible in a workplace setting with over 100 employees, numerous visitors, volunteers
and 80 plus residents. Introducing Sassy into this nursing home tested the total
A.L.I.V.E philosophy and its future.
Sassy bonded with Jacob a resident who was single, male, and who had
resigned himself to dying in the nursing home. In his words he “had nothing left to live
for” until Sassy came into his life. This two year relationship was remarkable to
observe. The administrator and community witnessed for the first time culture change in
action and began to understand the significance of the A.L.I.V.E philosophy.
There were daily walks, conversations, giving and receiving affection and shared
naps. The walks consisted of Sassy pulling Jacob in his wheelchair around the park,
down Main Street and they were known to stop at the local pub for liquid refreshments.
To experience life being poured back into Jacob’s world was refreshing. The dedication
between Jacob and Sassy was the breath needed to solidify the A.LI.V.E. philosophy as
an acceptable model for this long-term-care facility.
In retrospect this author would caution leaders not to have a live-in puppy. The
difficulty of consistent and routine training is an unacceptable risk to the overall success
of culture change. The second caution is to be aware of exclusive bonding between
facility live-in pets with an individual resident. Jacob lived for almost three years at this
facility. After Jacob’s death Sassy was devastated, she mourned and displayed
33

aggression toward others. Sassy became an unacceptable risk to the facility. The
survival of the A.L.I.V.E. program was in jeopardy. The administrator of this facility
made the decision Sassy would need to be euthanized. This was by far the most
difficult and important decision this leader made concerning the continuation of the
A.L.I.V.E. project.
When a leader chooses to “think outside the box”, there are tough decisions that
need to be made and those decisions usually are never black or white. There is more
to culture change than what can be contained within the four walls of the facility.
Leaders of a facility under culture change must be able to accept the critics and humbly
accept praise equally.
The step that set this facility apart from others is the intergenerational
programming. The implementation of the intergenerational program is the most recent
step towards culture change within this nursing home. In 2001, the introduction of 50
children sharing space with elders was met with trepidation and momentous concerns.
Parents of the children were concerned about the “old people harming their children”.
The families of the residents were concerned about the young “spreading all those kid
diseases” to the elders. Together they asked one single question: How was the facility
going to protect and keep their loved one safe?
Through an educational process and the positive actions of the staff the
administrator brought forth an understanding of the how each generation would benefit
from the other. Again, as demonstrated with the introduction of the animals there have
been no negative outcomes of the relationship between elders and children.
34

Over the past ten years the following transformations were implemented with the
understanding that there is no official completion date. Within each area of
implementation there is a constant evolution of culture change ideas. This facility’s
leaders understand that improvement and the expansion of culture change is
dependent on the residents they serve. The A.L.I.V.E. philosophy at this facility includes
but is not limited to the following beginnings:
• Live-in, facility-owned dogs, cats, birds, a rabbit, fish and plants were
introduced during the first 3 years of the program.
• Residents were also allowed to bring their own pets to live with them in
their new home in the third year of the program
• Cross training of staff was introduced for the first time on the facility’s
campus in 1999.
• The traditional chain of command of top down supervision was replaced
with a resident centered philosophy in 1999.
• In the year 2000, non-nursing staff were instructed to respond to a
resident’s call for assistance when the call light was illuminated. If a
resident was verbally calling out for help or if the resident appeared to be
in need of assistance, the staff person was to respond appropriately.
• The wings of the facility were transformed into neighborhoods in 2002,
with regular staff assigned from all departments including nursing,
housekeeping, rehabilitation, and activities.
35

• An intergenerational program comprised of 50 children sharing space with
the elders by eating together and sharing in curriculum based activities
was implemented in the year 2001
• Open meal times have been established. Specific set times for meals
were eliminated in 2006
• Departmentalization is being phased out within the nursing facility. This is
a long and tedious process which will be an ongoing process for many
years. Under this philosophy cross training of employees is an essential
paradigm shift.
Finally, the staff continues to be encouraged and supported as they continue to expand
their knowledge of positive approaches and creative methods in responding to the
residents’ requests and concerns.
Culture change takes place over an extended period of time; thus, the research
is limited and evidence based studies must be completed in order to change public
policies. This paradigm shift from the traditional medical model created copious and
innumerable questions from the initial team members, state surveyors, consumers and
the community.
However, even without hard data interest grows. As the culture change is
established, each discipline in a facility feels the effects. Department lines gray, as
black and white policies flex with the individual resident. Job descriptions and
responsibilities cross and decisions are made with the resident as the hub, and
employees adapt to new roles as the “spokes” of support. Cross training coupled with a
team centered attitude is the reality of culture change as seen with the diagram below.
36

Figure 6. Resident Centered Chain of Command
Each employee is equally responsible for the residents and to their physical,
social, spiritual and mental needs. They are allowed to focus on the consumer’s
strengths and interests with the full support of the leadership. It is clear that the resident
directs, and the employees respond. Culture change can be modified according to each
resident, staff member, and the personality of the community in which the facility is
located.
In summary, there are three major issues which confront long-term-care
nationally and state wide. Demographic studies demonstrate the graying of America.
As the Baby Boomer generation begins to age, an adequate workforce is essential for
Administrative
Assistant
Chaplain
Medicare
Maintenance
Housekeeping
Laundry
Beautician
URC-CDC
Business Office
Manager
Social
Services
Rehab
Recreation
Activities
Human
Resource
PPAL
Manager
Director
of Dietary
Director of
Nursing
Administrator
Administration
Resident
Administrative
Assistant
Chaplain
Medicare
Maintenance
Housekeeping
Laundry
Beautician
-
Child Development
Center
Business Office
Manager
Social
Services
Rehab
Recreation
Activities
Human
Resource
Assisted Living
Manager
Director
of Dietary
Director of
Nursing
Administrator
Administration
Resident
37

the level of care demanded, and for a life that screams quality. Staff must be able to
identify their needs and respond to their wants. The financing of this enormous task will
take center stage in policy debate and political platforms. Long-term-care managers
and leaders owe it to themselves, the residents, families, employees and the community
to minimize the negative and maximize the positive benefits of living and working
towards the changing culture in health care.
The essence of this important segment of the health care continuum is being
reshaped from its very core to the outer skins of society. Caught in the vise of
regulations, punitive survey processes, reimbursement reductions, related budget
restraints and staffing compromises, the long-term-care industry is rising above the
turbulent times and new ideas are emerging. In order for the culture change movement
to be sustained at the facility level, government policy and regulations will need to be
altered; medical providers must accept alternative methods of treatment; societal
attitudes toward nursing homes must be educated away, with elders themselves
learning about the aging process. Care giving must be looked upon as a profession
rather than an entry level job.
Lamenting about the quality of life and care in nursing homes occurs daily, along
with negative media stories, congressional hearings and government findings. Many
facilities are striving to change the image of nursing homes by changing the culture for
residents, employees, families and the communities they serve. In the mid 90’s a small
but determined group of early pioneers in the long-term care field worked to
fundamentally change the values, practices and culture of their respective
organizations. They began to create places for living and growing rather than for
38

declining and dying. In pockets across the country, four early pioneering approaches
were developed: the Regenerative Community, Resident-Directed Care, Individualized
Care, and The Eden Alternative.
As a director of a long-term-care facility it will be your responsibility to lead the
community in selecting an appropriate philosophy of culture change. As the leader you
may choose to immolate a nationally acceptable movement from those listed above.
The community may be receptive to creating a program designed by and specific to the
personality of the facility.
The administrator chose to design a philosophy that is reflective of the
community’s needs, traditions and values. The A.L.I.V.E philosophy is an important first
step of changing the culture of the nursing home. It is a conscious, visible, participatory
and living philosophy that is designed to assist the public in learning that life not death
can be found in long-term-care facilities locally and across the nation.
Figure 1. Rehab bird & Bonnie Figure 2. Marie with her quilt and
sewing machine
39

Figure 3. Playing hockey in the dining room Figure 4. Planting a tree of life
together
In the traditional long-term-care paradigm, predictability and control are the norm
for the nation’s facilities. The emerging paradigm shift is that 1% of the facilities are
focusing on eliminating the loneliness, helplessness, and boredom of the residents
living within a community which can be called “home” for those that live there.1
This
new view recognizes that nursing homes are adaptive to a new thought of service.
Everything or everyone cannot be tightly controlled. Instead, ideas for improving quality
of care and life for residents and employees alike come about when employees are
empowered to create new approaches under the direction of the resident and with the
support of the leadership and management.
Figure 5. Intergenerational event Figure 6. 6Sharing a mid-afternoon snack
1
Written permission received for photographs
40

This facility took a bold step in addressing the widespread belief that nursing
homes are a place to die. Through changing the culture within the nursing home, by
using the state university resources and by finding substantial financial support from the
community, the A.L.I.V.E philosophy will continue to lead the nation in culture change.
In closing, this author looked back at a 10 year career of this facility’s
administrator and found one nugget of information that a leader needs to know. A
leader that chooses to think outside the box and swim upstream against all odds needs
to accept that change of this magnitude takes time, dedication, commitment and a
fortitude that can overcome criticism and humbly take praise This facility has a bright
future.
Figure 7. Bring life & care to a resident Figure 8. The profession of caring for
and about the resident
41

References
Bowman, C (2006). Development of the artifacts of culture change tool. Retrieved March 4,
2007, from Development of the Artifacts of Culture Change Tool Web site:
http://siq.air.org/PDF/artifacts.pdf
Bowers, B (2001,November 30). Organizational change and workforce development in
long-term-care. Retrieved March 4, 2007, from Organizational Change and
Workforce Development in Long-term-care. Web site:
http://www.directcareclearinghouse.org/download/CULTURE5.doc
Department of Health and Human Services , OFFICE OF INSPECTOR GENERAL
INSPECTOR GENERAL (JULY 2003 ). OEI-09-02-00160 STATE OMBUDSMAN
DATA: NURSING HOME COMPLAINTS . Retrieved March 4, 2007, from NURSING
HOME COMPLAINTS Web site: http://www.oig.hhs.gov/oei/reports/oei-09-02-
00160.pdf
Evans, L & Scalzi, C, (Fall 2004). Culture Change in Long-term-care. Hartford Center of
Geriatric nursing Excellence. Retrieved November 6, 2006, from Culture Change in
Long-term-care. Hartford Center of Geriatric nursing Excellence. Web site:
http://www.nursing.upenn.edu/centers/hcgne/science_ltc.htm
Giguere, N (2006). Culture change in long-term-care. Retrieved November 5 from Culture
Change In Long-Term-Care 2006 Web site:
http://www.startribune.com/1758/story/454515.html
Hamilton, T (2006) Nursing home culture change regulatory compliance questions and
answers, Retrieved February 12, 2007, from Nursing home culture change
regulatory compliance questions and answers Web site:
http://www.lsni.org/whatsnew/CMSSCCultureChange.pdf
Haran, C (2006, April). Transforming long-term-care: Giving residents a place to call home.
The Common Wealth Fund, Retrieved November 6, 2006, from
http://www.cmwf.org/publications/publications_show.htm?doc_id=365728
Howorth, J (2005, March 12). Transforming long-term-care: Creating Human Habitats.
Retrieved November 8, 2006, from Transforming long-term-care: Creating Human
Habitats Web site: http://www.edenalt.com/pdf/Transforming%20Traditional
%20LTC.ppt
Kane, R, Kane, R, & Ladd, R (1998). The heart of long-term-care quoted in Paul R.
Willging, PhD, “It’s time to take the politics out of nursing home quality,” Nursing
Homes Magazine, January 2005, 22.. New York, NY: Oxford University Press.
42

Keane, B (2006). Building the new culture of aging: One leader at a time. Retrieved
November 8, 2006, from Building the new culture of aging: One leader at a time Web
site: http://www.nursinghomesmagazine.com/Past_Issues.htm?ID=3341
Minnix, L. (Ed.). (2006). The Long and Winding Road (1st ed., Vol. 1). West
Conshohocken: Decision Strategies International.
Minnix, L (2007, March). How your future might look. McKnight, 38-39
The NewsHour with Jim Lehrer, Kaiser Family Foundation/Harvard School of Public Health
(October 2001). Retrieved accessed December 5, 2006, from The NewsHour Web
site: http://www.pbs.org/newshour/health/nursinghomes/highlightsandchartpack.pdf
Thomas, W (1999). Learning from Hannah: Secrets for a life worth living. Acton,MA:
VanderWyk & Burnham.
Thomas, W (1999). The Eden alternative handbook: The art of building human habitats.
NewYork,NY: The Summer Hill Company, Inc.
Thomas, W (2004). What are old people for? How elders will save the world. Acton,MA:
VanderWyk & Burnham.
Witrogen-McLeod, B (2001). And thou shalt honor: The cargiver. Rodale, CA: Rodale Inc.
43

APPENDIX
ARTIFACTS OF CULTURE CHANGE TOOL
Artifacts of Culture Change
Home Name ________________________________________ Date _______________
City ___________________ State ___________ Current number of residents _________
Ownership: _____ For Profit _____ Non-Profit _____ Government
Care Practice Artifacts
1. Percentage of residents who are offered any of the following
styles of dining:
� restaurant style where staff take resident orders;
� buffet style where residents help themselves or tell staff
what they want;
� family style where food is served in bowls on dining
tables where residents help themselves or staff assist
them:
� open dining where meal is available for at least 2 hour
time period and residents can come when they choose;
and
� 24 hour dining where residents can order food from the
kitchen 24 hours a day.
_____ 100 – 81 % (5 points)
_____ 80 – 61% (4 points)
_____ 60 – 41% (3 points)
_____ 40 – 21% (2 points)
_____ 20 – 1% (1 point)
_____ 0 (0 points)
2. Snacks/drinks available at all times to all residents at no
additional cost, i.e., in a stocked pantry, refrigerator or
snack bar.
_____ All residents (5 points)
44

_____ Some (3 points)
_____ None (0 points)
3. Baked goods are baked on resident living areas.
_____ All days of the week
(5 points)
_____ 2-5 days/week (3 points)
_____ < 2 days/week (0 points)
4. Home celebrates residents’ individual birthdays rather
than, or in addition to, celebrating resident birthdays in a
group each month.
_____Yes (5 points)
_____ No (0 points)
5. Home offers aromatherapy to residents by staff or
volunteers.
_____Yes (5 points)
_____ No (0 points)
6. Home offers massage to residents by staff or volunteers. _____Yes (5 points)
_____ No (0 points)
7. Home has dog(s) and/or cat(s).
_____ At least one dog or one cat
lives on premises (5 points)
_____ The only animals in the
building are when staff bring
them during work hours
(3 points)
_____ The only animals in the
building are those brought in
for special activities or by
families (1 point)
8. Home permits residents to bring own dog and/or cat to live
45

with them in the home.
_____Yes (5 points)
_____ No (0 points)
9. Waking times/bedtimes chosen by residents. _____ All residents (5 points)
10. Bathing without a Battle techniques are used with residents. _____ All (5 points)
11. Residents can get a bath/shower as often as they would
like.
_____Yes (5 points)
_____ No (0 points)
12. Home arranges for someone to be with a dying resident at
all times (unless they prefer to be alone) - family, friends,
volunteers or staff.
_____Yes (5 points)
_____ No (0 points)
13. Memorials/remembrances are held for individual residents
upon death.
_____Yes (5 points)
_____ No (0 points)
14. “I” format care plans, in the voice of the resident and in
the first person, are used.
_____ All care plans (5 points)
Care Practice Artifacts Subtotal: Out of a total 70 points, you scored
__________.
Environment Artifacts
15. Percent of residents who live in households that are selfcontained
46

with full kitchen, living room and dining room.
_____ 100 – 81 % (100 points)
_____ 80 – 61% (80 points)
_____ 60 – 41% (60 points)
_____ 40 – 21% (40 points)
_____ 20 – 1% (20 points)
_____ 0 (0 points)
16. Percent of residents in private rooms. _____ 100 – 81 % (50 points)
_____ 80 – 61% (40 points)
_____ 60 – 41% (30 points)
_____ 40 – 21% (20 points)
_____ 20 – 1% (10 points)
_____ 0 (0 points)
17. Percent of residents in privacy enhanced shared rooms
where residents can access their own space without
trespassing through the other resident’s space. This does
not include the traditional privacy curtain.
_____ 100 – 81 % (25 points)
_____ 80 – 61% (20 points)
_____ 60 – 41% (15 points)
_____ 40 – 21% (10 points)
_____ 20 – 1% (5 points)
_____ 0 (0 points)
18. No traditional nurses’ stations or traditional nurses’
stations have been removed.
_____ No traditional nurses stations
(25 points)
_____ Some traditional nurses’
stations have been removed
(15 points)
_____ Traditional nurses’ stations
47

remain in place (0 points)
19. Percent of residents who have a direct window view not
past another resident’s bed.
_____ 100 – 51% (5 points)
_____ 50 – 0 % (0 points)
20. Resident bathroom mirrors are wheelchair accessible
and/or adjustable in order to be visible to a seated or
standing resident.
_____ All resident bathroom
mirrors (5 points)
21. Sinks in resident bathrooms are wheelchair accessible with
clearance below sink for wheelchair.
_____ All resident bathroom sinks
(5 points)
22. Sinks used by residents have adaptive/easy-to-use lever or
paddle handles.
_____ All sinks (5 points)
23. Adaptive handles, enhanced for easy use, for doors used by
residents (rooms, bathrooms and public areas).
_____ All resident-used doors
(5 points)
25
24. Closets have moveable rods that can be set to different
48

heights.
_____ All closets (5 points)
25. Home has no rule prohibiting, and residents are welcome,
to decorate their rooms any way they wish including using
nails, tape, screws, etc.
_____Yes (5 points)
_____ No (0 points)
26. Home makes available extra lighting source in resident
room if requested by resident such as floor lamps, reading
lamps.
_____Yes (5 points)
_____ No (0 points)
27. Heat/air conditioning controls can be adjusted in resident
rooms.
_____ All resident rooms (5 points)
28. Home provides or invites residents to have their own
refrigerators.
_____Yes (5 points)
_____ No (0 points)
29. Chairs and sofas in public areas have seat heights that vary
to comfortably accommodate people of different heights.
_____ Chair seat heights vary by 3”
or more (5 points)
_____ Chair seat heights vary by 1
3” (3 points)
_____ Chair seat heights do not
vary in height (0 points)
49

30. Gliders which lock into place when person rises are
available inside the home and/or outside.
_____Yes (5 points)
_____ No (0 points)
31. Home has store/gift shop/cart available where residents
and visitors can purchase gifts, toiletries, snacks, etc.
_____Yes (5 points)
_____ No (0 points)
32. Residents have regular access to computer/Internet and
adaptations are available for independent computer use
such as large keyboard or touch screen.
_____ Both Internet access and
adaptations (10 points)
_____ Access without adaptations
(5 points)
_____ Neither (0 points)
33. Workout room available to residents. _____Yes (5 points)
_____ No (0 points)
34. Bathing rooms have functional and properly installed heat
lamps, radiant heat panels or equivalent.
_____ All bathing rooms (5 points)
35. Home warms towels for resident bathing. _____Yes (5 points)
_____ No (0 points)
26
36. Protected outdoor garden/patio accessible for independent
use by residents. Residents can go in and out independently,
including those who use wheelchairs, e.g. residents do not need
assistance from staff to open doors or overcome obstacles in
traveling to patio.
50

_____Yes (5 points)
_____ No (0 points)
37. Home has outdoor, raised gardens available for resident
use.
_____Yes (5 points)
_____ No (0 points)
38. Home has an outdoor walking/wheeling path which is not a
city sidewalk or path.
_____Yes (5 points)
_____ No (0 points)
39. Pager/radio/telephone call system is used where resident
calls register on staff’s pagers/radios/telephones and staff
can use it to communicate with fellow staff.
_____Yes (5 points)
_____ No (0 points)
40. Overhead paging system has been turned off or is only
used in case of emergency.
_____Yes (5 points)
_____ No (0 points)
41. Personal clothing is laundered on resident
household/neighborhood/unit instead of in a general allhome
laundry, and residents/families have access to washer
and dryer for own use.
_____ Available to all residents
(5 points)
Environment Artifacts: Out of a total 320 points, you scored ___________.
Family and Community Artifacts
42. Regularly scheduled intergenerational program in which
children customarily interact with residents at least once a
51

week.
_____Yes (5 points)
_____ No (0 points)
43. Home makes space available for community groups to
meet in home with residents welcome to attend.
_____Yes (5 points)
_____ No (0 points)
44. Private guestroom available for visitors at no, or minimal,
cost for overnight stays.
_____Yes (5 points)
_____ No (0 points)
45. Home has café/restaurant/tavern/canteen available to
residents, families, and visitors at which residents and
family can purchase food and drinks daily.
_____Yes (5 points)
_____ No (0 points)
46. Home has special dining room available for family
use/gatherings which excludes regular dining areas.
_____Yes (5 points)
_____ No (0 points)
47. Kitchenette or kitchen area with at least a refrigerator and
stove is available to families, residents, and staff where
cooking and baking are welcomed.
_____Yes (5 points)
_____ No (0 points)
Family and Community Artifacts Subtotal:
Out of a 30 possible points, you scored __________ points.
Leadership Artifacts
48. CNAs attend resident care conferences.
_____ All care conferences
(5 points)
52

49. Residents or family members serve on home quality
assessment and assurance (QAA) (QI, CQI, QA)
committee.
_____Yes (5 points)
_____ No (0 points)
50. Residents have an assigned staff member who serves as a
“buddy,” case coordinator, Guardian Angel, etc. to check
with the resident regularly and follow up on any concerns.
This is in addition to any assigned social service staff.
_____ All new residents (5 points)
51. Learning Circles or equivalent are used regularly in staff
and resident meetings in order to give each person the
opportunity to share their opinion/ideas.
_____Yes (5 points)
_____ No (0 points)
52. Community Meetings are held on a regular basis bringing
staff, residents and families together as a community.
_____Yes (5 points)
_____ No (0 points)
Leadership Artifacts Subtotal: Out of a total 25 points, you scored
__________.
Workplace Practice Artifacts
53. RNs consistently work with the residents of the same
neighborhood/household/unit (with no rotation).
_____ All RNs (5 points)
_____ None = 0 points.
53

54. LPNs consistently work with the residents of the same
_____ All LPNs (5 points)
55. CNAs consistently work with the residents of the same
_____ All CNAs (5 points)
56. Self-scheduling of work shifts.
CNAs develop their own schedule and fill in for absent CNAs.
CNAs independently handle the task of scheduling, trading
shifts/days, and covering for each other instead of a staffing
coordinator
_____ All CNAs (5 points)
57. Home pays expenses for non-managerial staff to attend
outside conferences/workshops, e.g. CNAs, direct care
nurses. Check yes if at least one non-managerial staff member
attended an outside conference/workshop paid by home in past
year.
_____ Yes (5 points)
_____ No (0 points)
58. Staff is not required to wear uniforms or “scrubs.” _____ Yes (5 points)
_____ No (0 points)
59. Percent of other staff cross-trained and certified as CNAs
in addition to CNAs in the nursing department.
_____100 – 81 % (5 points)
_____ 80 – 61% (4 points)
54

_____ 60 – 41% (3 points)
_____ 40 – 21% (2 points)
_____ 20 – 1% (1 point)
_____ 0 (0 points)
60. Activities, informal or formal, are led by staff in other
departments such as nursing, housekeeping or any
departments.
_____ No (0 points)
61. Awards given to staff to recognize commitment to persondirected
care, e.g. Culture Change award, Champion of
Change award. This does not include Employee of the
Month.
_____ No (0 points)
62. Career ladder positions for CNAs, e.g. CNA II, CNA III,
team leader, etc. There is a career ladder for CNAs to hold a
position higher than base level.
_____ No (0 points)
63. Job development program, e.g. CNA to LPN to RN to NP. _____ Yes (5 points)
_____ No (0 points)
64. Day care onsite available to staff.
_____ No (0 points)
65. Home has on staff a paid volunteer coordinator in addition
to activity director.
_____ Full time (30 hours/week or
more) (5 points)
_____ Part time (15-30 hours/week)
(3 points)
55

_____ No paid volunteer
coordinator (0 points)
66. Employee evaluations include observable measures of
employee support of individual resident choices, control
and preferred routines in all aspects of daily living.
_____ All employee evaluations
(5 points)
Workplace Practice Artifacts Subtotal: Out of a total 70 points, you
scored __________.
Outcomes
67. Average longevity of CNAs.
Add length of employment in years of permanent CNAs and
divide by number of staff.
_____Your CNA average longevity
Above 5 years (5 points)
3-5 years (3 points)
Below 3 years (0 points)
68. Average longevity of LPNs (in any position).
Add length of employment in years of permanent staff LPNs
and divide by number of staff.
_____Your LPN average longevity
Below 3 years (0 points)
69. Average longevity of RN/GNs (in any position).
Add length of employment in years of all permanent RNs/GNs
and divide by number of staff.
_____Your RN/GN average longevity
56

Below average (0 points)
70. Longevity of the Director of Nursing (in any position). _____ Longevity as DON
_____ Longevity at home
71. Longevity of the Administrator (in any position). _____ Longevity as NHA
_____ Longevity at home
72. Turnover rate for CNAs. Number of CNAs who left, voluntary
or involuntary, in previous 12 months
divided by number of total CNAs
employed = turnover rate
Your home’s figure _______________
0 percent (5 points)
20-39 % (4 points)
40-59 % (3 points)
60-79 % (2 points)
80-99 % (1 point)
100% and above (0 points)
73. Turnover rate for LPNs.
Number of LPNs who left, voluntary or
involuntary, in previous 12 months
divided by number of total LPNs
0 – 12 % (5 points)
13-25 % (4 points)
57

26-38 % (3 points)
39-51 % (2 points)
52-65 % (1 point)
66 % and above (0 points)
74. Turnover rate for RNs. Number of RNs who left, voluntary or
involuntary, in previous 12 months
divided by number of total RNs
0 – 12 % (5 points)
13-25 % (4 points)
26-38 % (3 points)
39-51 % (2 points)
52-65 % (1 point)
66 % and above (0 points)
75. Turnover rate for DONs. ______ Number of DONs in
the last 12 months
1 (5 points)
2 (3 points)
3 (0 points)
76. Turnover rate for Administrators. ______ Number of NHAs in
the last 12 months
1 (5 points)
2 (3 points)
3 (0 points)
77. Percent of CNA shifts covered by agency staff over the last
month.
Total number of CNA shifts in a 24
hour period (all shifts no regardless of
hours in a shift) _____________
Multiplied by number of days in last
58

the last full month _____________
Of this number, number of shifts
covered by an agency CNA _______
________ Your percentage (agency
shifts/total number X days X 100)
0 % (5 points)
1-5% (3 points)
Over 5% (0 points)
78. Percent of nurse shifts covered by agency staff over the last
month.
Total number of nurse shifts in a 24
hour period (all shifts no regardless of
hours in a shift) _____________
Multiplied by number of days in last
the last full month _____________
Of this number, number of shifts
covered by an agency nurse _______
_______ Your percentage (agency
shifts/total number X days X 100)
0 % (5 points)
1-5% (3 points)
Over 5% (0 points)
79. Current occupancy rate.
_____Your home figure
Above 86 % (5 points)
At average 83-85 % (3 points)
Below 83 % (0 points)
(Using the national 2004 average of
84.2% from CMS)
Outcomes Subtotal: Out of a total 65 points, you scored _______________.
59

Artifacts Sections
Potential Points Your Subtotal Scores
Care Practices 70
Environment 320
Family and Community 30
Leadership 25
Workplace Practice 70
Outcomes 65
Artifacts of Culture Change 580 Grand Total
Developed by the Centers for Medicare and Medicare Services and Edu-Catering, LLP.
Formore information contact Karen Schoeneman at karen.schoeneman@cms.hhs.gov or
Carmen S. Bowman at carmen@edu-catering.com.
60

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